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0054 SANDALWOOD DRIVE - Health
"`54 Sandalwood Dri.ve (�'otuit A= 024— 056 r + C A Commonwealth of Massachusetts 0dq-- D6( f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments < % 54 Sandalwood Dr Property Address Terri Lynn Lavallee Owner O wner's Name . ,. information is Cotult / required for every V MA 02635 1-16-2020 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information SIB filling out forms p l4�1g3 on the computer, Darrell Stone use only the tab key to move your Name of Inspector cursor-do not Cape Cod Septic Inspection use the return key. Company Name P.O. Box 1466 Company Address Harwich Ma 02645 City/Town State Zip Code rn (508) 240-2500 S14995 Telephone Number License Number e B. Certification I certify that: 1 am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs F er Evaluation the`Local Approving Authority 4. ❑ Fails 1-17-2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health-or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 54 Sandalwood Dr Property Address Terri Lynn Lavallee Owner Owner's Name information is COtUIt required for every MA 02635 1-16-2020 page. Cltyrrown State Zip Code Date of Inspection C. inspection summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes:' ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure.is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts 6 Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Sandalwood Dr Property Address Terri Lynn Lavallee Owner Owner's Name information is required for every Cotuit MA 02635 1-16-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ElND (Explain below): ❑ obstruction is removed 0. Y . ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): I ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board-of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): r �r 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public.health, safety or the environment. . a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-.rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54 Sandalwood Dr Property Address Terri Lynn Lavallee Owner Owner's Name information is COtUIt required for every MA 02635 1-16-2020 page. Cltyrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. 0 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine m ne distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal 9 9 q to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection- orm = � Subsurface Sewage Disposal System Form,- Not for Voluntary Assessments •i 54 Sandalwood Dr Property Address Terri Lynn Lavallee Owner Owner's Name , information is COtUIt required for every MA 02635 1-16-2020 page. City/Town State Zip Code Date of inspection- C. Inspection Summary*(cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow .} ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed-at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this,form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. � , '. ❑ The system fails. l have determined that one or more of the above failure • criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well ` .t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts _ g� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Sandalwood Dr u Property Address Terri Lynn Lavallee Owner Owner's Name information is required for every Cotuit' MA 02635 1-16-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of'Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® 0 Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 i - c; Commonwealth of Massachusetts Title 5 Official Inspection. Form L Subsurface Sewage Disposal System'g pForm Not for Voluntary Assessments 54 Sandalwood Dr' Property Address Terri Lynn Lavallee Owner Owner's Name information is COtUIt 3 required for every MA 02635 1-16-2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: , a . Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 3 bedroom residential dwelling Number of current residents: 3 Does residence have a garbage grinder? , ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes No Laundry system inspected? ❑ Yes N No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes M No Last date of occupancy: Current t Date t5insp,doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 commonwealth of Massachusetts Title 5 Official Inspection Form t b Susurface Sewage Disposal Sysem Form - Not for Voluntary ry Assessments 54 Sandalwood Dr Property Address Terri Lynn Lavallee Owner Owner's Name information is required for every COtUIt MA 02635 1-16-2020 page. City/Town - State Zip Code Date of Inspection Do System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR'15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Unknown Was system pumped as part of the inspection? ❑ Yes ® No � If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: c5inso.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments NY 54 Sandalwood Dr Property Address Terri Lynn Lavallee Owner Owner's Name information is COtUIt required for every MA 02635 1-16-2020 page. City/Town State Zip Code. Date of Inspection Da System Information (cont.) 4. Type of System: _ ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval.' j ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2009 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate.on site plan): Depth below grade: 17"+/- feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: ' feet Comments (on condition ofjoints; venting, evidence of leakage, etc.): Apparent good condition t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 9 of 18 J Commonwealth of Massachusetts �rt Ig Title 5 official Inspection Form w Subsurface Sewage Disposal System Forme Not for Voluntary Assessments M e% 54 Sandalwood Dr Property Address Terri Lynn Lavallee Owner Owner's Name information is required for every Cotuit MA 02635 1-16-2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): ' 11" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 10" Distance from to of sludge to bottom of outlet tee or baffle P 9 22" Scum thickness 6" — Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grade to inlet cover 1" Normal liquid level No sign of leakage SCH 40 outlet tee Recommended next maintenance pumping within 1 year Recommended maintenance pumping every 2-3 years :5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts im I1F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c % 54 Sandalwood Dr u Property Address Terri Lynn Lavallee Owner Owner's Name information is COtUIt required for every MA 02635 1-16-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts ,.;p Title 5 Official Inspection Form > Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •, �� 54 Sandalwood Dr Property Address Terri Lynn Lavallee Owner Owner's Name information is required for every COtUIt MA 02635 1-16-2020 page. CityTown State Zip Code Date of Inspection D. System Information (cont.) S. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Grade to box 24" Cover 13" 4 outlets with speed levelers No scum Normal liquid level No sign of leakage OK condition No sign of failure t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 II __ Commonwealth of Massachusetts Ir Title 5 Official Inspection Form ': ,` 1 Subsurface Sewage Disposal,System (Form- Not for Voluntary Assessments 54 Sandalwood Dr , Property Address Terri Lynn Lavallee Owner Owner's Name information is COtUIt required for every MA 02635 1-16-2020 page. City/Town State Zip Code Date of inspection- D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pump's and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass' 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: , ❑ leaching pits,.-" ; number: ® .leaching chambers number: 24 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑' leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts I@ Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s �n 54 Sandalwood Dr Property Address Terri Lynn Lavallee Owner Owner's Name information is required for every COtult MA 02635 1-16-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) , Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 24 Infiltrators without stone Inspected with sewer camera Grade to SAS 60" Trace of liquid No sign of hydraulic failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form L „ice Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments ssments 54 Sandalwood Dr Property Address Terri Lynn Lavallee Owner Owner's Name information is required for every Cotuit MA 02635 1-16-2020 page. City/Town State Zip Code Date of Inspection D. System! Information (cont.) 13. Privy (locate on site plan): r Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure; level of ponding, condition of vegetation, etc.): c . � 1 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 15 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Sandalwood Dr V Property Address Terri Lynn Lavallee Owner Owner's Name information is required for every COtUIt MA 02635 1-16-2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Lo cate ocate where ublic water supplyenters P the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately FCC A O 2 OLY i B 25- 9 29- 1) I 2y-4 i 3 31- IC f 28- 2 4 i i I I f5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts r' �1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments </ 54 Sandalwood Dr , —u— Property Address Terri Lynn Lavallee Owner Owner's Name information is required for every Cotuit MA 02635 1-1612020. page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >5 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record " If checked, date of design plan reviewed: 2009 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: x Plan on file ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: A You must describe how you established the high ground water elevation: Engineer certified installation Bottom of SAS ELV. 94.0 Bottom of Test hole ELV. 87.0 NWE Separation >5' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts 11v , Title 5 Official Inspection Form = i. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . � 54 Sandalwood Dr Property Address Terri Lynn Lavallee Owner Owner's Name information is COtult required for every MA 02635 1-16-2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE LOCATION SEWAGE# o"ZB 09 9,S-4 ,�,, ,-VILLAGE Ca 0V °r ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. MG.C�C1�a to SEPTIC TANK CAPACITY oat) LEACHING FACILITY.(type) 55 �2 (size) X (o/ NO.OF BEDROOMS OWNER Trsc PERMIT DATE: a / COMPLIANCE DATE: Separation Distance Between the: / Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility °(— Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within t 300 feet of leach' facility) t Feet FURNISHED BY / n c- a 3�� 3� ` or ,r �` . TOWN OF BAR`NSTABLE =. S`ryw co SEWAGE # L. A.TiGN ` na r(ULAGE ���1Vt ASSESSOR'S MAP & L0 ` i� SZMLLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) /600 ,pit (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feer-of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i. IA �rt o q AA )l A® 3g� A `9 g Fee / o THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION v TOWN OF BARNSTABLE, MASSACHUSETTS pplication for Bid onl �&raem Con0truction Permit Application for a Permit to Construct( ) Repair�(<Upgrade( ) Abandon( ) ❑ Complete SysteXdividual Components Location Address or Lot No. `J L-k SO-- (Vk Lt't VOA A Owner's Name,Address,and Tel.No., Assessor'sMap/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7(.1 Type of Building: Dwelling No.of Bedrooms Lot Size '1 v sq. ft. Garbage Grinderl` /A Other Type of Building Ahl%P No.of Persons Showers J,, �Cafeteria( �� Other Fixtures Design Flow(min.required) gpd Design flow provided 3�3 i gpd Plan Date �� � J P� Number of sheets Revision Date r-- Title �Cr7i� Ct3��1{Cc.3( r Size of Septic Tank (� DO1) G� 1 Type of S.A.SJ Description of Soil CAC( Q`Lk Nature of Repairs or Alterations(Answer when applicable) \ e Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Deal Signe Date X c� Application Approved Date Application Disapproved by: Date for the following reasons Permit No. �,^�� Date Issued = No ^P ✓'� r. Fee t�*z THE COMMauW LTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes - RpPlicatiou for Migoal �&pgtem Conl5tructiou permit -Application for a Permit to Construct( )� Repair(.�)` Upgrade( ) Abandon( ) ❑ Complete Systerr>_L�dividual Components ja 1 �M J ocation Address or Lot No. SQ)ACA\W VIDA l�+lL Owner's Name,Address,and Tel.No. Assessor's Map/Parcel (gyp' 4 D S M Installer's Name,Address,and Tel.No. Cf*)(1- 3 j�.=i' S Designer's Name,Address and Tel.No. Type of Building: --T Dwelling No.of Bedrooms 3 Lot Size ~ JvV sq. ft. Garbage GrinderO/A Other Type of Building /L \Y_�Q No.of Persons Showers(L,;)- Cafeteria Other Fixtures Design Flow(min.required) gpd Design flow provided gpd k. Plan Date / 7 Number of sheets I Revision Date r^— Title e :5 SAQN Size of Septic Tank �,, DC)8 qT Type of S.A.S. -� to S p�PSS 1e Description of Soil Q- JP4 NO p\cr, �e ai Nature of Repairs\or Alterations(Answer when applicable) _b��os Date last inspected: 41 j Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by th's Board off liea Signe Y Date /5 Application Approved y. _ Date Application Disapproved by: Date for the following reasons i{ t ,,��ll t i Permit No. <7 � 4 DaatIssued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( Upgraded ( ) i Abandoned( )by at 5tA 5o,c\C\W 80 \\ls has been .,constructed �in/accordance with the provisions of Title 5 and tthhje�for Disposal System Construction Permit No. p900 —4 � T dated �� ����. Installer Man"� �(�CUyJS Designer ��=�(Y�C?(1 . #bedrooms 3 Approved design flow gpd The issuance of this permit shall notlbe2construed afa guarantee that the syst will function as designed. /Date l J �Cs" I Inspectors -.® No. ;�_ D(3 Fee THE COMMONWEALTH OE MASSACHUSEIrL TS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Mnigool �&p5tem Cow5truction Permit Permission is hereby granted to Construct ( ) Repair (x). Upgrade ( ) Abandon ( ) System located at If Li Sa,6c\L000A 'Dv-\J E \ and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditi MS. Provided: Construction .usst�be F om leted within three years of the date of this pe Date (� /d Approved b r Town of Barnstable �pFtHE Tp� y�P ti� Regulatory Services Thomas F. Geiler, Director * BARNSTABLE, 9 MASS. 0 Public Health Division Op i639. ♦0 A'EO3s� Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 8/27/09 Designer: Shay Environmental Services, Inc. Installer: Manny Barrows Address: P.O. Box 627 Address: West Falmouth Hwy. East Falmouth, MA 02536 West Falmouth, MA On 8/12/09 Manny Barrows was issued a permit to install a (date) (installer) septic system at 54 Sandalwood Drive, Cotuit, MA based on a design drawn by (address) Shay Environmental Services, Inc. dated 8/1W09 (designer) XX_ I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. � greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. (Installer s S.i.gi-iature) E. C�R f U No. 1101 "-k o ( signer's Signature) (Af1;, S Zp Here) ... ARlITAP,\P_ PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH ON. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form TRANS. NO.: ? I �1 (01 CITY/TOWN: �b� APPLICANT: \6Q.CZ`q Lyrig L RAJ At tit ADDRESS: 5L\ dsa e&,.\L'�W� `DQ ,CqB)T DESIGN FLOW: 3 gpd REVIEWED BY: DATE: N/A OK NO Legal boundaries denoted [310 CMR 15.220(4)(a)] Street, Lot, tax parcel number and lot number noted on plan [310 / CMR 15.220(4)(u)] V Locus Provided [310 CMR 15.2204(t)] Plan proper scale? (1"=40' for plot plans, 1"= 20' or fewer for / components) [310 CMR 15.220(4)] Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for upgrades]- if not, a variance is required [310 CMR 15.412(4)] Location of impervious surfaces (driveways, parking areas etc.) [310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR 15.220(4)(c)] Location and dimensions of system components and reserve areas. [310 CMR 15.220(4)(e)] System Calculations [310 CMR 15.220(4)(0] daily flow septic tank capacity(required and provided) soil absorption system (required and provided) whether system designed for garbage grinder North arrow [310 CMR 15.220(4)(g)] Existing and proposed contours [310 CMR 15.220(4)(g)] Location and log of deep observation holes (existing grade el. on each test) [310 CMR 15.220(4)(h)] Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h) and (i)] Location and date of percolation tests (performed at proper elevation?) [310 CMR 15.220(4)(1)] Percolation test results match loading rate? [310 CMR 15.242] Certification statement by Soil Evaluator [310 CMR 15.220(4)0)] Observed and Adjusted groundwater (method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)] Address Sheet 1 of 7 N/A OK NO Location of every water supply, public and private, [310 CMR 15.220(4)(k)] within 400 feet of the proposed system location in the case / of surface water supplies and gravel packed public water supply t� within 250 feet of the proposed system location in the case within 150 feet of the proposed system location in the case of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins located within 50 ft. [310 CMR 15.220(4)(1)] Water lines and other subsurface utilities located [310 CMR / 15.220(4)(m)] (if water line cross see 310 CMR 15.211(1)[1]) V Profile of system showing invert elevations of all system / components and the bottom of the SAS [310 CNM15.220(4)(o)] �/ Stamp of designer [310 CMR 15.220(1) and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3)] Test Holes adequate (two in each of the primary and reserve / unless trenches as permitted in 310 CMR 15.102(2) or as approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] Test hole adequate to demonstrate four feet of suitable material? [310 CMR 15.103(4)] Test Holes adequate to confirm adequate groundwater separation? [310 CMR 15.103(3)] Benchmark within 50-75' of system [310 CMR 15.220(4)(q)] Materials specifications noted? [various sections of 310 CMR 15.000] System components not > 36" deep (unless Local Upgrade Approval or LUA requested) [310 CMR 15.405(l(b)] Address �yc �Wc�oc` J�� `.� v i� Sheet 2 of 7 N/A OK NO Size OK? [310 CMR 15.223(1)] Inlet tee located ten inches below flow line [310 CMR. 15.227(6)] Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR / 15.227(6)] V Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)] Note regarding installation on stable compacted base [310 CMR / 15.228(1)] Separation between inlet and outlet tees (no less than liquid / depth) [310 CMR 15.227(2)] Inlet/Outlet elevations at least 12" above high groundwater / (except as described 310 CMR 15.227(5)) or permitted for t/ upgrades under LUA [310 CMR 15.405(1)(k)] Minimum cover 9" (Tanks buried more than 9" must have risers / on all openings and on the d-box) [310 CMR 15.2228(1) and 310 ✓ CMR 15.232(3)(f)] Three access covers (inlet and outlet must be 20" or greater) - middle access at least 8" (by 7/07) [310 CMR. 15.228(2)] Access to within 6 " of grade - one port for systems<1000gpd, two for systems >1000 gpd [310 CMR 15.228(2)] All at-grade covers secured to unauthorized access? [310 CMR / 15.228(2)] > 10 ft from building foundation [310 CMR 15.211(1)] Buoyancy calculation Required/Done [310 CMR 15.221(8)] H-20 Where appropriate? [310 CMR 15.226(3)] Setbacks from resources [310 CMR 15.211] Multi Corn artm�nt'I' n s �F� ��� � Required when other than single-family dwelling or flow>1000 gpd [310 CMR 15.223(1)(b)] First compartment 200% daily flow; Second compartment 100% 1/ daily flow [310 CMR 15.224(2) and (3)] "U" pipe through or over baffle, outlet of each compartment with gas baffle or approved filter [310 CMR 15.224(4)] Address___�y Sc�c\Q��,`� . , �'�[ 1 Sheet 3 of 7 N/A OK NO BIaLD �GR DOTHERI' PT A '. Located at least ten feet from any water line? [310 CMR 15.222(2)] Disposal piping at least 18" below water line (when water and sewer cross, see 310 CMR 15.21l(1)[1]) Cleanouts required/provided ? [310 CMR 15.222(8)] Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable [310 CMR 15.222(6)] Proper pitch on all runs? (.005 within gravity-distributed trenches and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] Siphon problem/ (leachfield below pump chamber) Endcaps or vent manifold specified? Size and orientation of discharge holes specified? (not smaller / than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) DISTR�TTJTI®N BfJXs �t" e U Stable compacted base [310 CMR 15.221(2) and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided? (when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a)] Riser if deeper than 9" [310 CMR 15.232(3)(f)] Inside minimum dimension 12" [310 CMR 15.232(2)(b)] Minimum sump 6" [310 CMR15.232(3)(e)] Watertight cover if<2000gpd); waterproof manhole if>2000gpd [310 CMR 15.232(3)(d)] Capacity(emergency storage above working=design flow)? [310 CMR 231(2)] Proper setbacks [310 CMR 15.211 (same as septic tanks)] Watertight 20-in minium access manhole at least 20" MUST BE TO GRADE [310 CMR 15.231(5)] Service components accessible (not too deep with piping, disconnects accessible) Alarm floats - alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag V mode. [310 CMR 15.231(6) and (8)] Stable Compacted Base [310 CMR 15.221(2)] Buoyancy calculations needed ? Provided? [310 CMR 15.221(8)] Address � (� �\,_s "iQ- ,� k u IT Sheet 4 of 7 • ,4 N/A OK NO Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240(1)] Required separation to groundwater? [310 CMR 15.212)] Aggregate specified as double washed [310 CMR 15.247(2)] System Venting required/provided? (system under driveway or / >36" deep) [310 CMR 15.241] i/ Inspection ports specified and within 3"final grade? [310 CMR / 15.240(13)] Breakout requirements met? (No violation of breakout elevation / arrier MR 15.211(l)[4] and V within 15 ft of SAS unless b 310 C Guidance Document] �GALZ�R�IES 'ITS�C' ER5�31�CMIZ5253 A a s 3 Chambers and Gal. in trench configuration supplied with inlet every 20 ft. [310 CMR 15.253(6)] Each structure with one inspection manhole (if>2000 gpd must / be to grade) [310 CMR 15.253(2)] V Aggregate 1' minimum- 4'maximum. [310 CMR 15.253(1)(b)] 2' sidewall credit maximum [310 CMR 15.253(1)(a)] In bed configuration, inlet every 40 sq. ft. [310 CMR 1.5.253(6)] Width T minimum 3'maximum [310 CMR 15.251(1)(b)] 100 feet- maximum length [310 CMR 15.251(1)(a)] Minimum separation 2x effective depth or width whichever greater(3x if reserve between trenches) [310 CMR 251(1)(d)] Situated along contours [310 CMR 15.251(2)] Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document] LZ BEDSSAS(Maxirnumsizeofbed,ofield��S000i?gpd) % 3 minimum 2 distribution lines [310 CMR 15.252(2)(a)] Maximum separation between lines 6' [310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6" minimum, 12" maximum. [310 CMR 15.252(2)(g)] Separation between beds 10' minimum. [310 CMR 15.252(2)(0] Bottom area used in calculations only [310 CMR 15.252(2)(1)] E Address san ��oan 11— Sheet 5 of 7 N/A OK NO DIfI� TI3kE�PIANtlx®gv x...,.,,.1; ..,3..�w.,..`� s^�.�';d� ,... .�rr._�,.,th.�c,.a.. ., •.,�..� ,a`�°�, ..F.._.. _ �..y.5'w,u.:���'S�. Pressure Dosed System ? Provided pump and piping calculations as required [310 CMR 15.220(4)(r)] Pressure dosing required on all systems>2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and I/A Remedial Use Approvals] If used in gravelless system -make sure jet is directed as not to scour soil interface [Guidance Document] V Inspections once per year (systems<2000 gpd) or quarterly / (>2000gpd) good to note on plan [310 CMR 15.254(2)(d)] �/ Construction in fill - Did the plan specify that the fill shall meet the specification of 310 CMR 15.255(3)? Impervious barrier and/or retaining wall ? [Guidance Document] Impervious barrier installation must be supervised by / designer [310 CMR 15.255(2)(b)] f/ Retaining wall must be designed by Registered Professional Engineer [310 CMR 15.255(2)(a)] V Side slope not exceed 3:1 ? [310 CMR, 15.255(2)] . Breakout requirements met? [310 CMR 15.252(2) and / Guidance Document] f/ At least 5 ft. from impervious barrier to edge of SAS (10 ft. recommended) [310 CMR 15.255 (2)(e)] �-Grl�eS .Syst�r�L�Y[I/f1PPro�v�aettersl��a° a� �''' W Check DEP Approval letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to scour soil interface Altenativese t .S stem IIA o�alLeler 7 ,� f Was DEP Approval Letter provided and/or have you / reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant submitted a copy of a maintenance _ ....� _ . Are the variances listed on the plan? [310 CMR 15.220 (4)(q)] RLS Stamp necessary on plan if a component is within five feet of property line [310 CMR 15.412(4)] New construction or increased flow proposed- [Refer to 310 CMR 15.414] c ` I Address �� cJQt��(k\14�C,� `(Q Sheet 6 of 7 N/A OK NO ,.w,.�_,s.<��.,s.ya :vr:ax .,,,�r.� ,��,�'✓ .�`r z���� �n f ,:r.�s, x.,%`-�' .' .' „� s.i.��'� ��? ;x, Is the system in a Designated Nitrogen Sensitive Area(Zone II for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.216 - also refer to Policy regarding upgrades of such �eS existing systems] Is the system proposed on the same lot as served by private well? [310 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR 15.216(1)] Pumping to septic tank ? [ 310 CMR 15.229] Shared System [310 CMR 15.290] � I Addres s Sheet 7 of 7 Town of Barnstable P# y Department of Regulatory Services ' Public Health Division Date f • eexrrsrnar8, � Muss. A 1639. ,6� 200 Main Street,Hyannis MA 02601 Date Schedul ed Time� Fee Pd. O Soil Suitability Assessment for Sew e isposal Performed By: Witnessed By: ✓�` �' LOCATION& GENERAL INFORMATION t Location Address Owner's Name 1 , . Address L A V��,1 R Assessor's Map/Parcel: Q j�75(o Engineer's Name NEW CONSTRUCTION REPAIR Telephone# S 35 -—39G Land Use `-'rc� 4`\ Slopes(40)_ �$ Surface Stones N Distances from: Open Water Body A ft Possible Wet Area J5D _ft Drinking Water Well A1 H ft _ Drainage Way . 'VPf ft Property Line Lit ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) v � '✓�t Parent material(geologic) C� � Depth to Bedrock /�I Depth to Groundwater. Standing Water in Hole:. /F Weeping from Pit Face Estimated Seasonal High Groundwater (3 r� ry SSUlti1Q DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in, Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.' Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Levi!], PERCOLATION TEST Dgtp-41co7rlln,e l;� w Observation Hole# '\ Time at 9" OAP Depth of Perc Time at 6" Start Pre-soak Time @ 1 Time(9"-6") End Pre-soak •�� Rate Min./Inch aM P Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one (1)week prior to beginning. Q:\SEPTICIPERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole#1_ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency.% ravel C,S o Yew . \ (2•51 -1-1I LSs70 DEEP OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. C nsi en %Gravel) �3 h -C a•s Coble. L DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% ravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consist n .t Flood Insurance Rate Map: • / Above 500 year flood boundary No Yes ✓__ Within 500 year boundary No Yes ` Within too year flood boundary No v Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pp- area material exist in all areas observed throughout the proposed for the soil absorption system? 25 If not,what is the depth of naturally occurring pervious mate rial`t -- Certification i I certify that on 1 (date)I have passed the soil evaluator examination approved by the Department of Enviro m ntal P to 'on d that the above analysis was performed by me consistent with the required training ex rti and x e ie ce described in 10 CMR 15.017. Signature Date Q:\SEpTICVERCFO RM.DOC ............................. 0 ------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD..� H ............................OF....... .. ... .................................... Appliratiou for Bhipoiial ]VorkLi Tomitrurtiou ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at ......... ..... .................................................................................................. Location-Address or Lot No. ....... ....... . . ... ........................................... .................................................................................................. Owner Address .............. ...... ........... .................................................................................................. Install e0l Address PQ t4 Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms-----.......................................Expansion Attic Garbage Grinder P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria P4Other fixtures ...................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow...........................................gallons. ,:4 Septic Tank—Liquid*capacity............gallons Length................ Width............... Diameter.___ ..._..... Depth................ Disposal Trench—No. .................... Width................ _ Total Length.................... Total leaching area....................sq. f t. Seepage Pit No--------------------- Diameter.._................. Depth below inlet.................... Total leaching area..................sq. ft. Other Distribution box ( ) Dosing tank ( I ) Percolation Test Results Performed by...........................................................:.............. Date........................................ j a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-___--__-_______--____-. Gz, Test Pit No. 2................minutes per inch Depth of Test. Pit.................... Depth to ground water-___-_-..._..__.....___. ......................................................................................""---------" ......""-------*......---------------- 0 Description of Soil.......................................................................................................................................................................... U ..............................................................................7.......................................................................................................................... .......................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ............I........................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual, Sewage Disposal System in accordance with the provisions of TL I T LE 5 of the State Sanitary Code--The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be 1 ue by the bird o g ne�d�-------- ----------------------------- ne I --------------------------------------- --------------- ApplicationApproved By............ ................................................................... Date in Application Disapprovedlyor Ille following reasons:................................................................................................................ ----------------------*......*.............*---------*--------------------------".......................................................................................... ...................... Date PermitNo......................................................... Issue(L...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOAR® F H - °,.... - -- _.....OF.......... . . ... . . _........................_. Appliration for Bispvii al Works Tvaut.rurtioat Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at - ........ _.. .-r ..... .............................................. Locations-Address or Lot No. ......- " `�-•----•-•-•- ............................................. .•-••---•••----•----•-•--•••-•............•--- W ' !` wner Address a =- ........ .............. ..... - Installe Address Type of Building Size Lot............................Sq. feet �., Dwelling—No. of Bedrooms._..._3.................................Expansion Attic ( ) Garbage Grinder ( ) a� Other—T e of Building No. of persons............................ Showers YP g ---------------------------- P (..--)--- Cafeteria ( ) dOther fixtures ------------------------•-------------••--------------••••--••-••-••••-•-•••-•--•----------------•-••••...... -----•---- W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons. C4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth.............. Disposal Trench—No. .................... Width.................... Total Length.................... Total leaclir>g area............ ---------sq. ft. Seepage Pit,No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. •1.................minutes per inch Depth of Test Pit.................... Depth to ground water...:---__--__-__---__--. fi, Test Pit No. 2....:...........minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •---•--------------------------•--••----....----.....----------....------....................................--••-•-•-:.....-•--•-......---................. 0 Description of Soil....................................................................................................................................................................... W UNature of. Repairs or Alterations—Answer when applicable-------------------------------------------- ................................................... ..................................-................................................................................------------------------------.......-----------------•......-•-•••......-••-.•-•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1L- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee i tied by the bd o iealth.. ........................• ----------- Application-Approved By. .. �"�' • :••• - ........ - ............... Date Application Disapproved. r t f ollowing reasons-------------•------------------------------------------•-----------------------•------------------•••----------- -•-------•----•-•-•----•-•••----•---------•-•--•---••---•-----••--•-•....•.--•--------------•-•-_........-•••-•--•--•--•--•••-----------•-•-•--•---•--•---•-----••••-•-•-•--•--•----•••......---••------ Date PermitNo.......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS ` BOAR OF H T .......................O F.... ................... .......................................................... �, Trrt firatr of Tootph ana THIS I 0, `RT E , Thee, Indivi Sewa DisposPIZ, ystem constructed ( or Repaired ( ) by ` .:.:_. ... .. r ---------------------------------------------•----------------. at.. J-�--��. 7 /, :. ,,---- dam" �'t ••------------•---------. ------•. has been installed in accordance with the provisions of TITLE 5 of heState Sanitary Code as described in the application for Disposal Works Construction Permit No---5.12,'.dl.`1j................... dated___,,'�.-/.� ..___........................ - THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE®W A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..........................................L[- 15J S�-•-•-••..... Inspector................... r`` .= THE COMMONWEALTH OF MASSACHUSETTS BOARD F HE,` JT f 6m ...........................OF....:.: /' ...L................................................... FEE........................ -.._. Cn o�"to�ry�ri '��ferat�t'i� .- ..................•-•---Permission is rebY granted.• . ------. to Construct "r-Re air ( an Ind�ivial Sevcags osal System ,r ------- v•o. -• r ....--••.... ...... at N Street j as shown on the application for Disposal Works Construction Permit No.. 1= Sr_._ Dated....... ............. a -- ' DATE..................................�� �= / Z........•• Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r _ Map Page 1 of 1 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ❑ Zoom Out ®nIn `p r R r y N [Ap. =_ 7PG Map: 024 024051 - Location: p11 Q Owner: N 4065 70 ' 010011 Location In p 75 . Map &Parce Location to Acreage Current Ow Mailing Addi 01D017 N61 10010005 € 4. 0?4056 14 054 Appraised D240D3 Extra Featur N 38 Li Out Building Land 0'1$ Buildings N 43 El Total Apprai 01D010006 � q 36 Assessed V Extra Featur 0 1 7 F et Out Building 024076 Land q 4L32_ _. Buildings Total Assess Set Scale 1" = 117 I Aerial Photos I MAP DISCLAIMER Copyright 2005-2009 Town of Barnstable,MA All rights reserved.Send questions or comm( BarnstableMA v1.2.3435 [Production] http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=024056&map... 6/10/2009 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 3 a TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM FOR PART A RECEIVE® CERTIFICATION pV 6a� d� MAY 14 2002 Property Address: 54 SANDLEWOOD DR COTUIT,MA 02635 Owner's Name: BLAKE TOWN OF BARNSTABLE i Owner's Address: PO BOX 2072 COTUIT MA 02635 HEALTH DEPT. f Date of Inspection: 5/2/02 ,, Name of Inspector: (please print)'l ` `JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET, MA.02536 Telephone Number: 508-564-68134AX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditifrtr es _ Needs Fluation by the Local Approving Authority Fails Inspector's Signature: Date: 5/2/02 The system inspector shall submitthis inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing1th►s�mspection.ditile system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit"the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent fQ the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL.LIFE. This report only describes conditions at the time of inspection and under the cuudilious of use 111 111111 liute. 111,111s inspection does not address how the system will perform in file future under the Same or differcul cuudilious of,us(.. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 54 SANDLEWOOD DR COTUIT, MA 02635 Owner: BLAKE Date of Inspection: 5/2/02 Inspection Summary: Check`A,B,C;D or.E./ALWAYS complete all of Section D A. System Passes: X I have not found any information_which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: , _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if.itl,is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old-is available. ND explain: n/a n/a Observation of sewage backup;pr`break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled o'r.uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced _ obstruction is removed distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction.is.removed ND explain: n/a a Page 3 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 54 SANDLEWOOD DR,COTUIT, MA 02635 Owner: BLAKE Date of Inspection: 5/2/02 C. Further Evaluation is Required by.the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless B o,a%r&of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, y safet and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2.. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning it a manner that protects the public health,safety and environment: f _ The system has a septic tan,k,and soit.absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic:tat Land SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS,and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance n/a **This system passes if the well water1.analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that rio other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a - . p,. .aa}. , fit•: 1E1 'Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) C Property Address: 54 SANDLEWOOD DR COTUIT, MA 02635 Owner: BLAKE Date of Inspection: 5/2/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each'of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped NOT BEEN Pl1MPED IN FIVE YEARS BV OWNER. X Any portion of the SAS,cesspool or privy is below high g1bund water elevation. X Any portion of cesspool or privy is.within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. IThis system passes if the well water analysis,performed at a DEP certified laboratory,jdi,coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails.,AI have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.`The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either".yes"or"no"to each of the following: (The following criteria apply..to large systems in addition to the criteria above) yes no X the system is within 400 feecof a surface drinking water supply X the system is within 200 feet'of a:t ibutary to a surface drinking water supply X the system is located-in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public watef:supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system hoS failed. The owner m.operaiol f►f any iltrf�e,Syslcln crntslrlPrPfl a .Slgni(icant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 ('MR 15.30,1. The sysiclu owner should contact the appropriate regional office of the Department. I, '1. Page 5 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 54 SANDLEWOOD DR COTUIT, MA 02635 Owner: BLAKE Date of Inspection: 5/2/02 Check if the following have been done.:You must indicate "yes"or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period `? _ X Have large volumes of water been introduced to the system recently or as part of this inspection '? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site'? X _ Were the septic tank manhole'uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge and depth of scum ? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no V X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] , zz 'Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 54 SANDLEWOOD DR COTUIT,MA 02635 Owner: BLAKE Date of Inspection: 5/2/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310'CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no)`'NO ' Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CM 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO ' Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title-5 system(yes or no): NO Water meter readings, if available: n/a, Last date of occupancy/use: n/a OTHER(describe): n/a I. GENERAL INFORMATION Pumping Records Source of information: NOT BEEN PUMPED IN FIVE YEARS BY OWNER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--:How was quantity pumped determined? n/a Reason for pumping: n/a' TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool r` _Overflow cesspool ,r _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and n—taintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval 4• Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 17 YEARS BY OWNEII � k Were sewage odors detected when arriving at the site(yes or no): NO a " . Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 54 SANDLEWOOD.DR_COTUIT, MA 02635 Owner: BLAKE Date of Inspection: 5/2/02 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction: _cast iron,X40 PVC_other(explain): n/a y Fi' Distance from private water supply.well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete metal_fiberglass_polyethylene other(explzin)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10 Sludge depth: 3" Distance from top of sludge to bottom of outlet-tee or baffle: 31" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 15" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) , Depth below grade: n/a Material of construction:_concrete_metal .fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outiet tee or baffle: n/a Distance from bottom of scum..to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,,etc.): _ n/a ai r `J1 t f . Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 SANDLEWOOD DR COTUIT, MA 02635 Owner: BLAKE r, Date of Inspection: 5/2/02 TIGHT or HOLDING TANK: ;(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(expla'in): n/a Dimensions: n/a R Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order.(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches, etc.): n/a DISTRIBUTION BOX: X(if present must be.opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): �. D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: -(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a r Page 9 of OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 SANDLEWOOD DR COTUIT, MA 02635 Owner: BLAKE Date of Inspection: 5/2/02 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a x Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: nla n/a leaching trenches, number, length: n/a n/a leaching fields, number: nla n/a overflow cesspool, number: n/a n/a innovative/alternative system i Type/name of technology: n/a ,i Comments(note condition of soil;signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE. PIT WAS HALF FULL AT TIME OF INSPECTION AND STAIN LINES INDICATE PIT HAS NEVER BEEN MORE THAN HALF FULL. BOTTOM OF PIT IS AT 8 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a , Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no):-NO Comments(note condition of soil,signs of hydraulic failure, level of ponding, con iition of vegetation,etc.): n/a PRIVY: (locate on site plan) i. ` Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs'of hydraulic failure, level of ponding, condition of vegetation,etc.): n/a Page 10 of I t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 SANDLEWOOD DR COTUIT,MA 02635 Owner: BLAKE Date of Inspection: 5/2/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. j �r�✓`� Cokdil. I� 1p 6 � P A6 AC 3� AD .3 4 y go 9 4 7 i 1t -Page I l of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 SANDLEWOOD DR COTUIT, MA 02635 Owner: BLAKE Date of Inspection: 5/2/02 SITE EXAM _Slope " _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record - If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators,,installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+ FT. f I l9 :CATI0M / SEI� AGE PE11MIT p0• � L.,o-� � l�- �� ,�/cam�a d � � 'r VILLAGE INSTAL.LER'S NAIRE & ADDRESS 9-YO• /y7,o ttr`Aj q- ,4 1?'y. A 13UILDER OR ICE DATE PERMIT ISSUED -3 e4 7— DATE COLA ►IIANCE ISSUED ,; /01A? �AAJd - 1 614G E FAM IL.-< - 3 btD RooM No GAARSAGE- -DA\LY FLow = SEPTiC -rANl 330Xi56`/, = `495G P- ? 100.1 o o 1 L V\sPOSAL P\T U5E -I C, C, GAL., si Dr--wA AVZ \sue A 99.s Bd<�UM AR�fx.* SosF. 9z.o 5 o G P. o, -ro rht.. D ES%C N - 4z5 �.P•D, qg\9 0ToT A L D A t L-Y F L O w = 3 3 C�G� IUD �0 PERcU�.q~�lary RATE t \N Cp- LESS, i tol.� Ioo•� ' qs•4 it , \ Q �l �E �- w• 114ti1 Q4 01 PiT .r3 war >'RoPoSE �3 r to N - i \0 o.pa M�K Go• L r _ ysr�+5� o 31 60.5 r5/ 5CA1,_ E 4OFT 33, 50U sCQ. F T, VIA COP TEs-T H ©t.._E E -fop a1; 77 . 7rr.� - tNY tti� sub o Sol+_ 95.z yq'4 Ir d(a0 C.A. � . o.0 \ O OQ S 6oX GNV. EPTt G 1ANcV•GA, I� riNV l.:l.4 lf.V ti Yp�MIL � M�tstuM ° LE N C- ti\ SAND i PlaC + j �t1TN p WASH E O t r, � r p n+ $Tot�►� f O l A No w A,T 2No PROF 1 �t� i k � SFr r E F �� + c � CS,I pLc��r PLt.N y. Ilk ►'�?' ,;,� 5 c \-E; AS ry o TF-Q l7 5 1 vi /e z. \ CERTtF`{ TN►"C <WM TYko ob.SG PVJ%W-1UCa PL AN R'EFERE-NG 5HQws4 HateatA COMP-YS WIt-'N -rNE SibtR.tf'kE A.mb s ra c>� � c u\ kYS or TKE Lp T \ -tawrr, it, `9 P 6• D^-TE: REGtSTF-:. -e-ID 1.hilp SVRVEYO TN\5 pLnt 1S NO-T A4 aST R�[lLlE - MASS, r \t,�STRU+"1--tO SUR-%/ P SEES 5"GuL.1:> ACCPt_.tCAWT • T)c>NA+,l-D SoUc-A,, NOT $E 05ET' i �E'�ER M►NE �oT L.\ S. 4 - I 2-18" DIAM. ACCESS MANHOLES 4 x ^�9 *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. VENT PIPE_j0 Least Ch Inches tall) Schedule 4o PVC w/Charcoal Odor Fllter ' �' `�" '' ✓� '�' � • . �,• ti" 're:,LL t" 10' min. from ESTABLISHED VEGETATIVE COVER ` ,� 4 ; £ ' ' e �Ar Existing Foundation house to septic tank ;,) i,; r ` S tic tank town must be D-80X cover must be I TOP OF FOUNDATION = ELEV. 100.00 within B In. of flnished grade wi in a in. of flntshsd grade - - - dade over Septic Tank g800 dad.over D-Box 9&00 over SAS 9&00 • ,�• ;y `.,�.., BACKFlLL WITH CLEAN SANG INLET f +.. +..1 ,i :. Y r....••v"„ ':v ►". , NATIVE OR PERC SAND) OU as x.ww t', r n ;•�:r' , .i' •,i.t..•• J : .rM r' s., .e• �•t v.w. ,!••'* ',1�a� N ,.+ I � •'� `.✓f ,•' ':3. AA• 'i ,t• ,.. .>'.. ,t', ar •,7+• �'.. µ �. '" a. wif'3`r l yr,•a•! ,' ;' r� .i.'..• .•'a° .r v, "'' :.� I'; A F THE TIC TANK, s I !•'` .. ..'� THE ACCESS COVERS OR E SEPTIC .; 'r:,:,.,, v: 0.02 B HOLE H-10 _ +' �;F; TOP OF UNIT ELEVATION 95.25 �•;• , t`:•f;;' ; DISTRIBUTION BOX AND LEACHING COMPONET r IST. BOX 3' Maximum Cover .: r + > + ,�,-.' -,+p*,►r r,•r":.s r+ '' S DEEPER THAN B INCHES BELOW FINISHED S 0.01 �: s ^;,.: ;•; v.i p «;af.i ►; .,.,:• . L •,. T ET 4►+e"r df + *✓' 4'PVC CAPPED INSPECTION PORT TO 8E l'• ;i. 7 �• i.;. t•'• EXISTING (CAPPED) ,.1 ,,. ._' •.,.� t�t` ti�n.':r 'i' , .,',,',�r GRADE SHALL BE RAISED TO WITHIN B' OF +" NSINb*�le rx1cT. PIPE 1000 GAL S. FlNI rr 2' INSTALLED AND TO MINNWITFMN 8' OF GRACE :, :s,! t! + g _. ,r, sD. 0.ot"per toot INV. ELEVATION - 94.75 ,',•,•�:•• , ,. .;:•'' .,.:;',` •``•• `v:" REINFORCED RECAST CONCRETE FROM EXIST, FOUNDATION N SEPTIC TANK ;�" a STEEL EINFORC P SHED ' .l �p a. ,� O 13' ' t. '4j. ' •; '. ,,Y�" ',w,' INSTALL TUF-TITE GAS BAFFLES OR EQUALS ./ ' i � "'s r- C PLAN VIEW ,.a 1 II H-10 ui c ..! CONCRETE wALK-our, N u xi BOTTOM ELEVATION - 94.00 JI 6 II n �6 3-24 REMOVABLE COVERS B In.of 3/4"-1 compacted atop. $ 4 SOWS OF!UNITS Al 4'/UNIT+ 2 END CAPS 26.00' . ; 5 MIN ABOVE BOTTOM OF 4» ,» GENERAL NOTES - > I TEST PIT OR GROUND WATER 6 s min. cleaan04 z t3" z SYSTEM PROFILE > m71 EFF. lI1DTE 12.70' EXISTING SUITABLE MATERIAL INLET mtn.T`�2_ min. inlet to outlet e.m VERIFICATION -` i Bottom of Test Hole 1 Elev.= 88.50 OUTLET 1. Contractor is responsible for Digsafe notification, Not to Scale B In.of 3/4.-1 1/2" GROUNDWATER NOT OBSERVED t0.mM, (� LqT""�t4 r' compacted stone c GROUNDWATER NOT OBSERVED 0 132 _- IT and protection of all underground utilities and pipes. NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 8" BELOW GRADE - s -7" a, �__ } ,.s' -7" 2. The septic"tank a J distrl Ltion box shall be set BOTTOM OF TP-1.: - 87.00 S❑IL ABS❑RPTI❑N SYSTEM (SECTION) level on 6 of 3�4 -1 1�2 stone. ESHWT = NO GROUNDWATER OBSERVED 0 132" a.. r' ;: L4iQuc d.pih 3. Backfill should be clean sand or gravel with no INFILTATROR QUICK 4 (H-10 L❑ADING)/ GEORGE ❑'BRIEN + bs stones over 3" in size. (OR EQUIVALENT) ;� 4. This system is subject to inspection during installation . - ' i Carmen E. Shay - Environmental Services Inc. NOTE OVERALL HEIGHT OF INFILTRATOR IS 12" ' ` • '' `' by y , �_D• 4' -10• 5. The contractor shall install this system in accordance CROSS SECTION END-SECTION with Title V of the Massachusetts state code, the approved plan and Local Regulations. _ 6. If, during installation the contractor encounters any TYPICAL 1000 GALLON SEPTIC TANK soil conditions or site conditions that are different NOT TO SCALE from those shown on the soil log or in our design installation must halt & immediate notification be -° made to Carmen E. Shay - Environmental Services, Inc. 7. No vehicle or heavy machinery shall drive over the PERCOLATION TEST P 12 614 septic system unless noted as H-20 septic components. 8. Install Tuf-rite gas baffles or equals on all outlet tee ends. Date of Percolation Test: JULY 1, 2009 9. All Distribution Lines shall be 4" diameter Sch. 40 NSF PVC pipes. ,l' Test Performed By. CARMEN E, SHAY, R.S., C.S.E. 10. All solid piping, tees & fittings shall be 4" diameter Results Witnessed By: DAVID STANTON - Barnstable BOH Schedule 40 NSF PVC pipes with water tight joints. EXCAVATOR: Shay Env. Svcs. Percolation Rate: <2 MPI 0 36 11. MUNICIPAL WATER IS AMAILABLE TO THE SITE and Surrounding Properties. NO PRIVATE WELLS WITHIN 150 FEET of PROPOSED SAS Test Hole Test Hole No. 1 No. 2 DEPTH SOILS ELEV. DEPTH SOILS ELEV. 0 98.00" 0 98.00 THE PROPERTY LINES ARE APPROXIMATE AND Sandy Loam Sandy Loam COMPILED FROM THE PLAN BY BARTER & NYE OF OSTERVILLE, MA 10 YR 3/2 �� 10 YR 3/2 MA, ENTITLED "CERTIFIED PLOT PLAN OF LOT #31 (#54) SANDALWOOD, Ip DRIVE, COTUIT, MA DATED MAY 19, 1986. 9 0 -6" o -6 A AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN Loamy and Loamy and IT SHOULD BE USED FOR NO PURPOSE OTHER THAN oJ� 10 YR s 10 YR 3/e THE SEPTIC SYSTEM INSTALLATION: O , 6"- 36" 8, 95.00 6"- 36" B• 95.00 Q Mod-Coors Mod-Coors Sand Sand NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE 2.3 Y 7/4 25 Y 7/4 FROM THE EXISTING LEACH PIT TO BE DISPOSED ,' ,' 00g 36"- 132 G 87.00 36"- 132 G 87.00 OF AS PER BOARD OF HEALTH SPECIFICATIONS. / �/ �t6 FILLEDEXISTING N PLACE PIT TO BE PUMPED DRY & / ' ,el/ /' // �/ /� / 00 ASSESSORS MAP 24 PARCEL 056 , / � / / / ,� ZONING - RESIDENTIAL , � � /' / ♦ / / � �� Pert #1 Depth to. Pe 36" to 54" WETLANDS ARE LOCATED WITHIN A 200' RADIUS / Perc Rate= <2 MPI OF THE PROPERTY AND ARE AS SHOWN LOT #31 I,'°� %/ i/ /, / / %/ / �6 NO Groundwater Observed 0 132" 33,600 S 'oars Feet + i ADJUSTMENT = NONE 4 /- , � � i / WETLANDS LOCATION FROM PLAN BY BARTER & NYE OF OSTERVILLE, MA / // / , No Observed ESHWT " �� / � � � � / /�� ��. ENTITLED CERTIFIED PLOT PLAN OF LOT 31 (#54) SANDALWOD DRIVE COTUiT, MA" DATED 5/19/86. ALL OUTLET PIPES FROM THE (p� DISTRIBUTION BOX SHALL BE 12" CONCRETE COVER TEST -HOLE J#2 LEVEL FT.SET FOR AT LEAST 2 ELE I, 98.00/ , , / / / , . KNOCKOUTS LEGEND -... r 1 ��• � / _ / % % ' ` / M % ' G y' 6 - 5" OUTLET ; 'u r..s, ::..�,,, 2" v / �' / j ��0 - 1s.s" OUTLET j . 12" INLET 88X0 DENOTES PROPOSED PROJECT BENCH MARK / t / / i / '/� / O e" <•'• SPOT GRADE TOP OF FOUNDATION TEST HOLE 1 ELEV. = 100.00 (Assumed) ' ELEV.- 98.1 0 ! ; / J rl // / o / i/ i ,' / // O P ;. - 2 DENOTES EXISTING 1s.s" 4" scH. 40 T 1.75" X 104.46 SPOT GRADE PLAN-SECTION CROSS SECTION PL PROPERTY LINE ° 6 HOLE DISTRIBUTION BOX PROPOSED CONTOUR -'T NOT TO SCALE 97- - -- - -97 EXISTING CONTOUR �'`\ EXIST. , / Design Calculations , . DRIVEWAY r i I I I , , I / I / / - �� 1, Failed i `�\ •. i i , ; I r � � ' I f �I / � 1 �/ � DEEP TEST HOLE & LEACH PIT PERCOLATION TEST LOCATION / O Number of Bedrooms: 3 Equivalent to 330 Gal./Day �� I I DECK I I I I l l I I l l l m Garbage Grinder, No I I l I i ; I �i / / i 0 Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V) FENCE Septic Tank - 2 x 330 Gal./Day - 660 USE EXIST. 1,000 GAL. Septic Tank. O SOIL ABSORPTION AREA: Using percolation rate of <2 min./Inch PRIVATE DRINKING WATER WELL D-Box I I I I I I / i / I I O Bottom Area: 0.74 gal/sq. ft. x 490.88 sq. ft. 365.25 gallons I I i 1 I I iI i 1 ZZ Sidewall Area: NOT USED Providing: = EXISTING I I ► 1 , REVISIONS ��\ f 3 BEDROOa! i i i I I I I / 1 i 1 I I g: 363.25 gallons ROUSE I I I I I l 1 / / / Z Use: 4 ROWS OF 6-OUICK4 STANDARD CHAMBER UNITS WITH NO NO. DATE: DEFINITION Of 2 O #54 I I I I STONE FOR AN SAS HAVING THE DIMENSIONS: 12.7 x 26.0 Oj I EXIST. I ; I ( I I j 1 I t 3 Bottom Area: (General Use Approval for 4.72 SF/LF of INFITRATOR Q I Vent 1000 gal, I I I I I ; 1 I ► / U_ 6 UNITS + 2 END CAPS per ROW = 26.0 FT O 3 I Pipe Septic Tank I I , I , I I ► I i = LL AIL I I I I , I i i / Ii I I I i O 4 ROWS x 26.0 x 4.72 SF/LF 490.88 O I -------- ' i ' I 1 I I 43.7 I I W DESIGN FLOW PROVIDED: 0.74(490.88 S.F.) = 363.25 GPD LLJ ,,,- 1 � � I i I ( l ► , , I I EXIST. y I , ► I I l l I I PROPOSED DRIVEWAY i I I I I i I I I I I I I I I I I I I , , Bedroom PREPARED FO R e 1 I , ► I I I I 1 M Bedroom SUBSURFACE SEWAGE DISPOSAL SYSTEM m I Attic Storage OF `.; ' ; ; I I ► ; ,off TERRYLYNN LAVALLE 54 SANDALWOOD DRIVE ��``. / 1 I i i I I I I I I I ( I I �Z 2nd Floor I I I I I I I Ial COTUIT MA In 1 �Z` #54 SANDALWOOD DRIVE ;� \ •� >585 ,i i i i ► ' I j I 1 ' Igl COTUIT, MA 02635 PREPARED BY: / >N 79�� at l / /r Bedroom m° m Kitchen W / / i I I I I ► ` ` I F '4� zs» CA.RHEAT E. SHAY , 1 I , I Living Dining o� CAR • EVVVIRONMENT.�4L SERVICES, INC. Room Room E. 20 40 50 �,� ro I ' I 1 It 185 ASHUMET ROAD CO Qo , c0 4 1 ; , MASHPEE, MA 02649 i` 1st Floor SAN rAR`P`� SCALE: 1"=20' TEL/FAX 508-539-7966 3 BR HOUSE FLOOR SCHEMATIC (Description Provided By Owner) SCALE: 1 "=20' DRAWN BY: CES DATE: AUGUST 10, 2009 PROJECT#SD-1152 ILENAME: SD1152PP.DWG SHEET 1 OF 1